When I read a recent meta-analysis by Paul Marik, the first thing I did was bang my head against the wall 10 or 20 times. For seven years I have been trying to get people to put in neck lines because we KNOW the infection and DVT risk is lower, right? Well Dr. Marik's review may significantly lower our certainty. You remember Paul Marik; he was on the show discussing fluid responsiveness a few months ago. He is a Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center.

Well, let's get to the actual meta-analysis on femoral central lines first...

The Meta-Analysis

Marik, Flemmer, et al. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: A systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug;40(8):2479-85.

Some of the Component Articles

Nagashima et al. To reduce catheter-related bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization? J Infect Chemother. 2006 Dec;12(6):363-5.

Lorente et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005; 9(6): R631–R635.

The Two Studies from Wales by Harrision et al.: 2009 data, 2010 data

The Plots

Femoral vs. Subclavian

Femoral vs. IJ

What to make of all this?

I believe the data from this meta-analysis still show that neck lines have less infection risk than groin. But what this article does establish quite a bit of doubt on this answer. I think this will allow for further trials, though the numbers will have to be large and the study well done. ANZICS can you help us please???

Update:

This trial looked at IJ vs. femoral by using data from 2 RCTs of biopatchs. Up until the 5 day mark, no difference between the two sites. ( American Journal of Respiratory and Critical Care Medicine 2013;188: Jugular versus Femoral Short-Term Catheterization and Risk of Infection in Intensive Care Unit Patients. Causal Analysis of Two Randomized Trials )

This newest trial puts subclavian definitively on top (N Engl J Med 2015; 373:1220-1229)

What do you think? Leave your thoughts in the comments below.

Now on to the Podcast: